Provider Forms

Samaritan Advantage HMO Plans – Conventional, Premier, Premier Plus & Special Needs Plans 

You have the option to submit authorizations online through your provider portal, Provider Connect.

Appeal Request Form
Case Management Referral Form
Hepatitis C Therapy Prior Authorization Form
Medication Redetermination Form
Member Request to Change PCP Form
Prescription Mail Order Transfer Form – to transfer member prescription drugs to Samaritan Health Services Pharmacy for mail order
Prior Authorization Form
Prior Authorization Form Instructions
Rx Exception/Prior Authorization Form
Waiver of Liability Statement – Non-contracted providers must include a signed Waiver of Liability form holding the enrollee harmless in order to request a reconsideration of the plan’s denial of payment. The reconsideration must be filed within 60 calendar days from the remittance notification.

Samaritan Employer Groups Plans – Standard, Performance, Everyday Choices, and Momentum

You have the option to submit authorizations online through your provider portal, Provider Connect.

Prior Authorization Form
Prior Authorization Form Instructions
RX Exception/Prior Authorization Form
Hepatitis C Therapy Prior Authorization Form
Appeal Request Form

Samaritan Choice Plans for Employees of Samaritan Health Services

You have the option to submit authorizations online through your provider portal, Provider Connect.

Prior Authorization Form
Prior Authorization Form Instructions
Rx Exception/Prior Authorization Form
Hepatitis C Therapy Prior Authorization Form
Disabled Dependent Determination Form
Prescription Mail Order Transfer Form – to transfer member prescription drugs to Samaritan Health Services Pharmacy for mail order
SamFit/SAM Physical Therapy Reimbursement Request Form
Appeal Request Form

You have the option to submit authorizations online through your provider portal, Provider Connect.

Appeal Request Form
Care Coordination Request Form
Case Management Referral Form
Hepatitis C Therapy Prior Authorization Form
Individual Flexible Service Request Form (Request health-related services that OHP does not cover. Review the flexible services instructions.)
Interpreter Services Input Template for Providers
Member Request to Change PCP Form
Opioid Tapering Plan Form
Prior Authorization Form
Prior Authorization Form Instructions
Rx Exception/Prior Authorization Form